Arizona Hospital Discharge Data
Limited Data Set
Data Use Agreement
MAIL this Data Use Agreement, the Application form, supporting documentation and payment by check or money order only to:
Arizona Department of Health Services
Bureau of Public Health Statistics
Section of Cost Reporting and Discharge Data Review150 North 18th Ave - Suite 550
PhoenixAZ 85007-3248
Requestor information:
Principal Requestor Name: E-Mail: Phone:
Organization Name:
Data Use Restrictions and Agreement:
The Principal Requestor is the Contact Person for the Organization and by signing this document makes this agreement binding upon the Organization. Should the Principal Requestor cease affiliation with the Organization, the Organization must identify a new Contact and the Arizona Department of Health Services notified immediately of the change.
The requesting Organization, by signature of the Principal Requestor as authorized representative, hereby provides the following attestationsregarding the use and protection of the Arizona Hospital Discharge Data Limited Data Sets:
1)We will not use or disclose any portion of the data for any purpose other than the purpose(s) described in our Application document;
2)We will safeguard the data from unauthorized access;
3)We will not release any patient-level data or individual patient records nor any part of them to any person or entity not specifically identified in the supporting documentation submitted with this Data Use Agreement;
4)We will not attempt to identify or contact individuals;
5)We will not attempt to link the individual records of patients in this data with any other individual level data or individual level information from any other source;
6)We will not copy, sell, rent, license, lease, loan, or otherwise grant any access of any kind to the data covered by this Agreement to person or entity who is not identified in the supporting documentation submitted with this Agreement.
7)We understand that the Organization is responsible for appropriate use and protection of the data to which we have been granted access, and that violation of the terms of this Agreement will result in denial of access to Arizona Hospital Discharge Data and may make the Organization subject to prosecution under HIPAA;
8)We will notify ADHS in writing within forty-eight (48) hours of learning of any violation of this Agreement;
9)We will indemnify, defend and hold harmless the Arizona Department of Health Services, its employeesand contract vendors from any and all claims or losses accruing to any person or entity as a result of violation of this agreement;
10)We understand that the Arizona Department of Health Services retains ownership of the data;
11)We understand that the maximum length of time we may retain data received is 5 years, at which time the data must be completely destroyed, and a Certificate of Destruction must be submitted to the Arizona Department of Health Services. Certificate of Destruction is available on the Department website.
12)We will make no statement indicating or suggesting that interpretations drawn from the data are those of the Arizona Department of Health Services;
13)If cited in a publication or presentation, the source of the data shall be acknowledged as the Arizona Hospital Discharge Limited Data Set, Bureau of Public Health Statistics, Arizona Department of Health Services.
Attestation:
I am authorized by the Organization identified in this document to bind them to the terms of this agreement; I have read this document in its entirety, I understand the content of this document, and I have indicated such by affixing my signature below.
Principal Requestor Name:______Title:______
(please print)
Signature: ______Date: ______
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